Champva Meds By Mail Details

If you are a veteran who has recently been discharged from active duty, you may be wondering what benefits you are eligible for. One benefit that may be available to you is the VA Form 10 0426. This form can help you obtain disability compensation from the Department of Veterans Affairs (VA). In this blog post, we will discuss what the VA Form 10 0426 is, and how to complete it. We will also provide tips on how to submit your application for disability compensation.

You'll discover details about the type of form you would like to prepare in the table. It will tell you how much time it will take to finish va form 10 0426, exactly what parts you will need to fill in and a few further specific details.

QuestionAnswer
Form NameVa Form 10 0426
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesva form 10 0426, veteran affairs form 10 0426, champva prescription claim form, va form 10 0426 printable

Form Preview Example

Department of Veterans Affairs Meds by Mail Order Form

A mail order prescription service for qualified CHAMPVA and Spina Bifida beneficiaries

This form is for Prescription Orders Only

Important Information

This form must be filled out completely including your Social Security number and Date of Birth for identification purposes. If you cannot be identified, your prescription will not be filled.

Attach the original prescription to this form. Photocopies of prescriptions are not accepted.

This order form is required EVERY TIME a written prescription from your medical provider is mailed.

This form is to be completed by the patient, family member, or caregiver with power of attorney.

Use a separate form for each patient or family member.

Medication delivery may take up to 21 days from the date you mail your order. To ensure that you have enough medication to last until your shipment arrives, request a second written prescription for a 30-day supply from your medical provider that can be filled at your local pharmacy.

This mail order service is provided only for maintenance medicationthat is, medications that are required for extended periods of time. All immediate-use or one-time-use prescriptions and all CII controlled substance prescriptions must be obtained at your local pharmacy.

Patient Prescription Information

This form must be filled out completely - TYPE or PRINT information below:

Patient Name: (Last, First, Middle Initial)

Patient SSN

Date of Birth (mm-dd-yyyy)

Mailing Information (Type or Print where the prescriptions are to be mailed)

Patient Mailing Address:

Daytime Phone Number (Including Area Code):

Address 1

 

 

Home:

 

 

Cell:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address 2

 

 

 

 

 

 

 

 

 

 

 

 

Today's Date:

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

NON-SAFETY CAP REQUEST:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal law requires that your medication be dispensed in a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

Zip

 

 

 

 

 

 

 

 

 

container with a child resistant or safety cap. If you would like your

 

 

 

 

 

 

 

 

 

 

 

prescription with an “Easy-Open” lid, please sign below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I request that these prescriptions and all refills of these

Is this a change of address?

Yes

No

 

 

 

 

 

 

 

 

prescriptions dispensed in “Easy-Open” or NON-child-resistant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this a permanent change?

Yes

No

 

 

 

 

containers.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this a temporary change?

Yes

No

 

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication Allergies

 

 

 

 

 

 

 

 

 

Health Conditions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No known allergies

 

 

 

 

 

 

Arthritis

Glaucoma

Liver Disease

 

 

 

 

 

 

 

 

 

 

 

 

Aspirin

NSAIDS

 

 

 

 

Asthma

Heart Problem

Seizures/Epilepsy

 

 

 

Cephalosporin

Penicillin

 

 

 

 

COPD

High Cholesterol

T Thyroid

 

 

 

Codeine

Sulfa

 

 

 

 

Depression

Hypertension

Ulcer/Acid Reflux

 

 

 

Erythromycin

Tetracycline

 

 

Diabetes

Kidney Disease

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify)

 

 

 

Food Allergy (specify)

VA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM

10-0426

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 2

 

JAN

2016

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM

10-0426

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 2

DEC 2016

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Where to Mail your Prescriptions:

WEST

 

EAST

 

If you live in one of the following states or

If you live in one of the following districts, states or

territories, mail your order form to the address

territories, mail your order form to the address

listed below:

 

listed below:

 

Alaska, American Samoa, Arizona, Arkansas,

Alabama, Connecticut, Delaware, Florida,

California, Colorado, Guam, Hawaii, Idaho, Illinois,

Georgia, Kentucky, Maine, Maryland,

Indiana, Iowa, Kansas, Louisiana, Michigan,

Massachusetts, Mississippi, New Hampshire,

Minnesota, Missouri, Montana, Nebraska, Nevada,

New Jersey, New York, North Carolina, Ohio,

New Mexico, North Dakota, Northern Mariana

Pennsylvania, Puerto Rico, Rhode Island, South

Islands, Oklahoma, Oregon, South Dakota, Texas,

Carolina, Tennessee, Vermont, Virginia, Virgin

Utah, Washington, Wisconsin, Wyoming.

Islands, Washington D.C., West Virginia.

 

 

 

 

Telephone:

1-888-385-0235

Telephone:

1-866-229-7389

Address:

Meds by Mail

Address:

Meds by Mail

 

PO Box 20330

 

PO Box 9000

 

Cheyenne, WY 82003-7008

 

Dublin, GA 31040-9000

 

 

 

 

How to Request Prescription REFILLS:

This form is for use when you send a paper prescription written by your medical provider. Refill orders should be placed by calling our automated refill system. Simply call 1-888-370-1699 and follow the voice prompts. Refill orders may also be placed using the refill slip that accompanies each shipment of medication. If you choose to reorder by mail, be sure to return your refill slip as soon as you receive your prescription order, as it may take up to 21 days to process your order. DO NOT DELAY in requesting your refills. Read the refill slip carefully, it contains information you will need concerning the number of refills remaining and the prescription expiration date.

E-prescribing Information

We now accept electronic prescriptions directly from your doctor. Ask your doctor if they can e-prescribe and tell them the name of the pharmacy is listed as: “Meds by Mail CHAMPVA”

Provider Information

Provider Name:

Provider Contact:

VA FORM

10-0426

Page 2 of 2

DEC 2016